Health Plans

Today’s healthcare market is rapidly changing, so you need a different kind of business advisor. One that understands your business, the unique challenges to your specific organization and the interrelated nature of many of these challenges. Baker Tilly’s team of Value Architects™ are here to help.

    By the numbers

    Health Plans: Membership and Premium Cycle Audits

    20

    Top 20 healthcare consulting management firm (Modern Healthcare 2020)

    70+

    Serving more than 70 health and medical insurance companies

    6

    6th largest health insurance auditor (A.M. Best 2021)

    60%

    Working or qualified to work in 60% of states using external specialists

    Our solutions

    Baker Tilly can help you and your organization address and align the significant number of business and technical challenges facing your business. In collaboration with you, we bring all the pieces together to architect, design and build the right solutions. From assurance and tax to risk and technology transformation, our truly unique approach has us delivering projects “with you” not “to you.” Our equal focus on process, organization and technology integration provides a refreshing alternative to both large accounting and health plan consulting organizations as well as vended software solutions.

    Health plans operate in a highly regulated environment and face a variety of complicated tax implications. At Baker Tilly, we understand both the insurance and healthcare markets. Whether it’s preparing or reviewing your financial statements, gaining a better understanding of accounting standards and practices, developing a compressive tax strategy or something outside of the box, our team of assurance and tax professionals are here to help.

    Assurance and tax solutions

    The most effective compliance programs are those that adhere to current, and that can adapt to looming, regulatory requirements and enforcement initiatives. At Baker Tilly, we understand that business can’t stand still, and neither can your compliance program. We provide innovative cost-effective solutions to address your business’ unique situation through our compliance program auditing and monitoring, compliance operations, compliance program evaluation and advisory, and workforce compliance training solutions.

    Compliance solutions

    Whether your organization is looking to sell, refinance, acquire a competitor, or anywhere in-between, your company needs a trusted advisor to maximize value and minimize risks. Baker Tilly’s team of Value Architects™ are able to help companies at all stages of the business lifecycle, and can help your organization with its financial operations, transactions, corporate tax and complex valuation concerns.

    Transaction advisory solutions

    Health plans continue to face numerous external pressures and evolving challenges that prevent management from making informed decisions. Whether it’s adhering to data privacy security laws and the Health Insurance Portability and Accountability Act (HIPAA), helping your organization gain or maintain HITRUST certification, or protecting your company’s and members’ sensitive information through proper cybersecurity controls and remediation, our team of risk advisory specialists are here to help. We can also help your organization set up and optimize your company’s internal audit function to anticipate future needs and emerging risks.

    Risk advisory solutions

    New regulations and industry trends that affect the health plans industry continue to emerge (e.g., the Interoperability and Patient Access final rule, price transparency regulations, the No Surprises Act, etc.). As such, health plans should continue to think beyond a pure compliance perspective and utilize their digital transformational journey as a strategic opportunity to create efficiencies and maximize their return on investment (ROI). In addition, health plans need to take into consideration the affect that process changes will have on both existing and new technology systems that are integrated within and outside of the organization. At Baker Tilly, we understand both the regulatory and technological aspects that affect health plans. We also understand that enterprise-wide technology transformation involves operational readiness, customer engagement and compliance teams working together. Whether it’s helping align your technical strategy for compliance purposes or making an existing process more efficient, our team of Value Architects™ can help with your technology transformation needs.

    Enhancing operational efficiencies, providing more engaging customer experiences, and addressing the current talent shortage remains a concern for health plans. To help address these concerns, health plans are continuing to turn to robotic process automation (RPA), automation intelligence (AI) and other forms of automation software and programs. At Baker Tilly, we work with our clients to drive effective process automation solutions that address the unique situation for each company so that we can determine the right technology needed to enhance your processes and to make your organization successful.

    Healthcare information technology and automation solutions

    Customers and program sponsors are continuing to demand better quality and more cost-effective healthcare. As such, it is imperative for health plans to continue to adopt and scale strategic value-based care (VBC) payment programs as well as closely collaborate with internal and external stakeholders (e.g., healthcare providers, life sciences companies, etc.). From analytical models that value incentive earnings, to platforms that allow collaboration on actionable insights, to core operations that support value-based strategies, we understand the challenges involved with enabling your value-based program strategies. By applying the Baker Tilly solution framework that also relies on our experiences and understanding of the entire healthcare ecosystem, your organization can operationalize and scale to a full panel of programs needed to enable your VBC strategy.

    Value-based care programs and network management solutions

    With Medicare Advantage memberships continuing to rise, it is essential that health plans administering Medicare Advantage programs take an integrated organizational approach that addresses the needs of all internal and external stakeholders. At Baker Tilly, we are able to offer an integrated set of solutions to help your organization build and optimize your Medicare Advantage program’s objectives and related operational capabilities. We are able to help design and optimize your Medicare Advantage network, administer value-based contracts and other value-based reimbursement models, formulate capitation arrangements, manage your risk adjustment program and establish an effective data management platform.

    Medicare advantage program optimization solutions

    Risk optimization programs require new operational capabilities, consisting of both new and pre-existing systems, processes and datasets built in collaboration with other VBC and care management programs. At Baker Tilly, we understand the strategies necessary to optimize risk adjustment, while simultaneously delivering additional value and better performance across your VBC, care management and quality programs. We can help you and your organization’s risk optimization strategy through organizing and integrating member data, developing powerful and flexible insights, orchestrating and improving performance of engagement activities, managing the quality and effectiveness of submission data, and optimizing program performance.

    Risk optimization solutions

    Multiple competing business, clinical and consumer experience objectives can often create challenges in executing a truly consumer-centric program. With Baker Tilly’s consumer engagement strategy, we are able to help build and maintain a sustainable, consumer engagement capability that can deliver positive, relevant experiences for your plan members while also supporting your critical programs. Our services include acquiring, managing and organizing individual-level data; building meaningful insights about individuals; integrating and aligning processes and systems; and developing and managing content and assets. We also can also help you and your program so that you are interacting with consumers at the right time, with the right message and via the right channel.

    Consumer engagement solutions

    Ready to connect about our health plans solutions?

    Our clients

    “They are more than consultants. The Baker Tilly team raised the quality of our internal audit and risk management functions and helped us through the change management required to ensure success. We are extremely pleased with their work.”
    -Craig Campbell, Chief Administrative and Risk Officer, WPS Health Solutions, Wisconsin Physicians Service Insurance Corp.
    Customer segmentation provides foundation to increase customer life time value

    The pace of change in today’s healthcare market is accelerating.

    Change is rapidly transforming the health plan industry in areas that previously had long-term stability, including a greater need to collaborate with industry partners and stakeholders as the industry continues to shift from the traditional volume-based to value-based care (VBC) arrangements — increasing the complexity to adjust or requiring additional bandwidth to address disruption. From adapting to the coronavirus pandemic, to increasing demands of delivering sustainable medical expenses reductions, to the growing threat of large-scale disruption from insurtech and inter-industry mergers and acquisitions, health insurance companies need both accounting and health plan consulting specialists with deep knowledge and experience in both healthcare and insurance.

    Baker Tilly’s specialized professionals understand the interconnected nature of these key challenges. Contact our team of health plan specialists who provide solutions that establish a solid fiscal and regulatory base by enhancing organizational operations.